Emergency Mental Health Service Program Initial ...



DEPARTMENT OF HEALTH SERVICESDivision of Quality AssuranceF-00551 (06/2024)STATE OF WISCONSIN PAGE \* MERGEFORMAT 1 of NUMPAGES \* MERGEFORMAT 5DHS 34 EMERGENCY MENTAL HEALTH SERVICE PROGRAMSInternal Use OnlyINITIAL CERTIFICATION APPLICATION Date Received: FORMTEXT ?????Questions regarding this form may be directed to the Division of Quality Assurance (DQA), Behavioral Health Certification Section (BHCS) at DHSDQAMentalHealthandSubstanceUseCertification@dhs..Submission of this information is required by Wis. Stat. §§ 50.065 and 51.45 and Wis. Admin. Code chs. DHS 34. Failure to provide complete and accurate information may result in denial of the application and /or delay in the process. An application is considered complete when all applications are received with accurate information, signatures, and supporting documentation, and when the background check report resulting from Step 1 is available for review by the Behavioral Health Certification Section.STEP 1 – ENTITY OWNER BACKGROUND CHECKS (ECBC)The applicant submits background information documents and fee directly to the Office of Caregiver Quality (OCQ). See below.Note: Background materials should not be submitted with the certification application.ECBCs must be completed for entity owners, whether or not the owner has direct client contact. Certification will not be issued until the ECBC has cleared and results are approved.For information on how to complete the ECBC, visit assistance completing this form, call OCQ at 608-261-8319.STEP 2 – COMPLETED APPLICATIONThe applicant submits all applicable documents listed in this section and the BHCS staff will review to ensure compliance with applicable regulations.A completed application includes each of the following:This application form, fully completed and signed by the entity owner or board memberAll supporting documentation as specified in the applicationFees as specified in the applicationEmail application and supporting documents to: DHS DQA Mental Health and Substance Use Certification Mail the required fees with “Initial App [Provider Name] DHS 34” in the memo line to:DHS/DQA/BAL/Behavioral Health Certification SectionPO Box 2969Madison, WI 53701-2969Please Note: The application will not be processed until a completed application, supporting documents, and all fees are received in full. All fees are non-refundable.Fees for New Provider:Biennial Fee - $1,100.00.Fees for Existing Provider:If adding this service, please reach out via email to determine your current cycle and correct fees. Please include your current certification number on the email.STEP 3 – ONSITE SURVEYA BHCS surveyor will contact you to arrange a date and time for an onsite survey.Refer to DQA publication P-63174, Survey Guide: Behavioral Health Certification for Mental Health and Substance Abuse Services.If the surveyor identifies significant changes that would result in a denial decision, the applicant will be afforded an opportunity to make necessary changes and submit those changes for review.STEP 4 – APPROVAL OR DENIAL DECISIONThe surveyor will make the certification decision and send the survey results to notify the provider of the decision.If approved, BHCS staff will email a formal certificate to the provider for posting at the primary clinic location.GENERAL INFORMATION – ENTITY/ENTITY OWNER REQUESTING CERTIFICATION FORMCHECKBOX Initial Certification FORMCHECKBOX Change of Ownership – Provide current certification number: FORMTEXT ????? FORMCHECKBOX Adding Service to Existing Certificate – Provide current certification number: FORMTEXT ?????Facility General InformationFacility Name (Should match signage and Medicaid enrollment, if applicable) FORMTEXT ?????Facility Street Address FORMTEXT ?????Location – Street Address/Room No. FORMTEXT ?????City FORMTEXT ?????ZIP Code FORMTEXT ?????County FORMTEXT ?????Facility Phone Number FORMTEXT ?????Facility Fax Number FORMTEXT ?????Facility Web Address FORMTEXT ?????Facility Contact InformationName Contact Person FORMTEXT ?????Will program obtain Medicaid certification? FORMCHECKBOX Yes FORMCHECKBOX NoFacility NPI Number (if known) FORMTEXT ?????Contact Phone Number FORMTEXT ?????Contact Email Address FORMTEXT ?????Physical Address – Street FORMTEXT ?????City FORMTEXT ?????County FORMTEXT ?????State FORMTEXT ??ZIP Code FORMTEXT ?????Designated Mail Recipient (Check and provide requested information for all that apply)Name – Designated Mail Recipient FORMTEXT ?????Title FORMTEXT ?????Email Address FORMTEXT ?????Mailing Address – Street or PO Box (if different from above) FORMTEXT ?????City FORMTEXT ?????State FORMTEXT ??ZIP Code FORMTEXT ?????Entity Owner InformationType of Entity (Check only one) FORMCHECKBOX Church FORMCHECKBOX Corporation – Business FORMCHECKBOX Corporation – Non Profit FORMCHECKBOX Government – County FORMCHECKBOX Government – State FORMCHECKBOX Government – Other FORMCHECKBOX Tribal FORMCHECKBOX Limited Liability Corp (LLC) FORMCHECKBOX Proprietorship (Individual) FORMCHECKBOX Partnership FORMCHECKBOX Other – Specify below: FORMTEXT ?????Name – Owner (Individual/Partnership Names) or Corporation (Legal Entity) FORMTEXT ?????FEIN* – Legal Entity FORMTEXT ?????Name – Owner/Board Member FORMTEXT ?????SSN* – Owner or Board Member FORMTEXT ?????Address – Street FORMTEXT ?????City FORMTEXT ?????State FORMTEXT ??ZIP Code FORMTEXT ?????Telephone – Owner/Board Member FORMTEXT ?????Fax – Owner/Board Member FORMTEXT ?????Email Address – Owner/Board Member FORMTEXT ?????* Collection of the applicant’s Social Security number (SSN) and Federal Employer Identification number (FEIN), if applicable, is required per Wis. Stat. § 73.0301 to verify compliance with Wis. Stat. § 51.032. Failure to supply the number may result in denial of the application. This number will only be disclosed to the Department of Revenue for use in collection of tax delinquencies.Program InformationNameTelephone NumberFax NumberEmail AddressProgram Contact FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Client Rights Specialist FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Program Director/Administrator FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Clinical Coordinator FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Record Custodian FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoHave you informed your clients (both former and present) that they may be contacted by the DQA surveyor? FORMCHECKBOX Yes FORMCHECKBOX NoAre you accredited by any organizations, other than DQA? If “yes,” identify accreditation organization and provide accreditation identification. FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoDoes your agency have a contract with the 51.42 Board? If “yes,” identify county/counties. FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoHave you every operated a residential facility, health care facility, or day care program for adults or children in Wisconsin or in any other state? If “yes,” explain and provide relevant information. FORMTEXT ?????Disclosure of OwnershipRequired Supporting Documentation – Submit these required documents, when applicable: FORMCHECKBOX List of names, principal business address, and percentage of ownership interest of all officers, directors, stockholders owning 5% or more of stock, members, partners, or others having authority or responsibility for the operation of the organization. For non-profit or governmental organizations, list the names and principal business addresses of all officers and board members. FORMCHECKBOX A diagram reflecting the ownership structure and names of any affiliate organization associated with the entity owner (parent corporations, other LLC, partnership, etc.) FORMCHECKBOX If there are no additional owners, check here.Entity Owner AttestationI hereby attest that all staff know and understand the rights of the clients that they serve and the procedures of informal and formal resolution and have read Wis. Admin. Code chs. DHS 92 and 94. The above-named program has appropriate policies to meet Wis. Admin Code chs. DHS 92 and 94 to ensure patient rights, patient records, confidentiality, and informed consent. The program has a designated client rights specialist who is trained in compliance with the requirements of Wis. Admin. Code chs. DHS 92 and 94, Wis. Stat. ch. 51, and federal HIPAA requirements in 45 CFR 164 Part E and 42 CFR Part 2, as applicable.I attest, under penalty of law, that the information provided in this application and in attached application materials is truthful and accurate to the best of my knowledge and that knowingly providing false information or omitting information may result in a fine of up to $10,000 or imprisonment not to exceed six years, or both (Wis. Stat. § 946.32).I attest that I will comply with all laws, rules, and regulations governing program certification in Wisconsin.SIGNATURE – Owner or Board Member (Full signature is required)Date Signed FORMTEXT ?????Name – Owner or Board Member (Print or type) FORMTEXT ?????Title – Owner or Board Member FORMTEXT ?????Entity Owner Transfer of Responsibility to Request Future Changes and Clinical OperationsThe individual in the role specified below is given full authority to request initial services and branches, service additions and deletions, staff changes, branch location additions and deletion, and all operational changes submitted to the department.Check applicable role: FORMCHECKBOX Program Contact FORMCHECKBOX Program Director/Administrator FORMCHECKBOX Clinical CoordinatorSIGNATURE – Owner or Board Member (Full signature is required)Date Signed FORMTEXT ?????Name – Owner or Board Member (Print or type) FORMTEXT ?????Title – Owner or Board Member FORMTEXT ?????INITIAL SERVICES CERTIFICATIONReview and complete the section fully; submit the specified additional documentation.Required Supporting Documentation FORMCHECKBOX All Policy and Procedures for DHS 34AttestationI hereby attest that all statements made in this application and any attachments are correct to the best of my knowledge and that I will comply with all laws, rules, and regulations governing DHS 40 services, including Wis. Admin. Code chs. DHS 92 and 94 and Wis. Stat. ch. 51. The signatory of this document is duly authorized by the licensee/certificate holder to sign this agreement on its behalf. The certificate holder hereby accepts responsibility for knowing and ensuring compliance with all licensing, operational, and requirements for this facility.I attest under penalty of law that the information provided above is truthful and accurate to the best of my knowledge.I understand that knowingly providing false information or omitting information may result in denial of licensure, a fine of up to $10,000 or imprisonment not to exceed six years, or both (Wis. Stat. § 946.32). SIGNATURE – Entity Owner, Representative, or Authorized Representative Specified AboveDate Signed FORMTEXT ?????Full Name (Print or type) FORMTEXT ?????Title FORMTEXT ?????EMERGENCY MENTAL HEALTH TREATMENT STAFF LISTINGName – Facility FORMTEXT ?????Facility Address – Street Address FORMTEXT ?????City FORMTEXT ?????ZIP Code FORMTEXT ?????NamePositionVerification Signature *DateDegreeKnowledge ofApplicable Parts of Chapters 48, 51, 55 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No* Verification Signature – Verifies that the above experience and knowledge factors are correct and that there is a criminal record check on file.I affirm that the above statements are correct to the best of my knowledge.SIGNATURE – Facility DirectorName – Facility Director (Print or type) FORMTEXT ?????Date Signed FORMTEXT ????? ................
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